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Technical report
peer-reviewed

Deep Brain Stimulation for Essential Vocal Tremor: A Technical Report



Abstract

Essential vocal tremor (EVT) is the presence of a tremulous voice that is commonly associated with essential tremor. Patients with EVT often report a necessary increase in vocal effort that significantly worsens with stress and anxiety and can significantly impact quality of life despite optimal medical and behavioral treatment options. Deep brain stimulation (DBS) has been proposed as an effective therapy for vocal tremor, but very few studies exist in the literature that comprehensively evaluate the efficacy of DBS for specifically addressing EVT. We present a technical report on our multidisciplinary, comprehensive operative methodology for treatment of EVT with frameless, awake deep brain stimulation (DBS).



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Technical report
peer-reviewed

Deep Brain Stimulation for Essential Vocal Tremor: A Technical Report


Author Information

Allen L. Ho Corresponding Author

Department of Neurosurgery, Stanford University School of Medicine

Omar Choudhri

Department of Neurosurgery, Stanford University School of Medicine

C. Kwang Sung

Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center

Elizabeth E. DiRenzo

Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center

Casey H. Halpern

Department of Neurosurgery, Stanford University School of Medicine


Ethics Statement and Conflict of Interest Disclosures

Human subjects: This study did not involve human participants or tissue. Animal subjects: This study did not involve animal subjects or tissue. Conflicts of interest: The authors have declared that no conflicts of interest exist.


Technical report
peer-reviewed

Deep Brain Stimulation for Essential Vocal Tremor: A Technical Report


Patient Reported Outcome

Patient name: Sharon Camboia

The tremors that I felt for years had become a part of me. In the beginning, as far back as my childhood, I can remember my “shakiness” being present. The reason for being shaky, however, always seemed justifiable through the years. Whether it be nervousness as a child, or a stressful day at work, as an adult there was always a valid explanation for my shaky hands. As a child, I can also remember my mother having the same symptoms that progressed into my adulthood. Again, my mother had a diagnosis of diabetes, and low blood sugar was usually the culprit of her tremors. There always seemed to be a reason for our unwelcomed shakiness. Having a reason made them seem a normal response. I had no reason to question my symptoms.

Approximately six years ago, at the age of fifty, the “normal” tremors I had been feeling all my life began to change. The nerves or stress-induced shakiness that I had grown accustomed to began to stay with me without explanation. My new symptoms had become constant, sometimes weaker, but nevertheless consistent. I woke up with shaky hands that within weeks progressed into the inability to function normally. Simple things, such as placing toothpaste on my toothbrush had become a chore. Over the next few months, the tremors that once remained in my hands had spread throughout my arms and, at times, into my legs as well. My life as I knew it was completely changed.

I quickly sought explanation through my primary physician, who first offered medication to help “control” my symptoms, often causing additional unwanted side effects. Without any positive effect I again asked for alternative treatment. I was referred to a neurologist in my home town of Merced, California. A CT scan of my brain was taken, and I never received any results. Without any new findings, I continued to search for an explanation and a cure through an additional referral to another neurologist,  Dr. Ma in Turlock, California, which led me thirty minutes out of town; an easy drive for answers. Many neurological tests were run. A repeat CT scan, MRI, blood tests to rule out multiple sclerosis and Parkinson’s disease were all conducted with “normal” findings. Negative results are supposed to be positive. However, my negative results left me without answers… and the tremors remained. Again another new medication was offered and tried with a minimal effect on my shakiness.

I began to alter my position in the business I have owned for seventeen years. I began to close myself off to the general public more and more. This tremor had found a way into every minute of my day, and affected each step in my everyday routine. I regularly turned down social appointments to avoid the feeling of embarrassment that came along with the inability to place a fork to my mouth during an afternoon lunch. My tremors had taken over, and in 2014 they had invaded my voice as well. At this point, even when I spoke, the reminder of my tremor presented itself in a tone, and vibration that made my voice sound decades older. The embarrassment that I felt just increased with my new symptom. A difficulty swallowing accompanied it as well.

At this point, multiple medications had been trialed without success, although the side effects had seemed to slow down my movement and alter my mood. I felt depressed at the idea that this would remain my life. I began to try to adjust to the idea that this was it, the tremors, and my new shaky, sometimes un-recognizable voice were here to stay. I was still determined to push for answers and I continued to ask Dr. Ma for new treatment options. She decided to refer me to Stanford Medical Center.

Once at Stanford, I was excited at the possibility of a diagnosis that would allow, at the least, a decrease in my tremors, which would allow me to regain some of my life back. My appointment was with Dr. Kilbane, neurologist. Dr. Kilbane conducted an extensive assessment of my tremors as well as my overall health. We reviewed every medication I had tried over the last 2 years. I was amazed that after two hours in her office she presented me with a diagnosis: Essential Tremor or Familial Tremor. To rule out any other diagnosis, however, Dr. Kilbane once again ordered testing and labs that again returned as normal. The Essential Tremor diagnosis was confirmed. I was impressed with the knowledge they had to offer me.

At this point, Dr. Kilbane offered one more medication for me to try. I was hesitant, but for the first time she also offered me an alternate treatment. She explained that this was the last medication we would try together. In addition, with their education and my own personal research they could offer me a surgical intervention called DBS (Deep Brain Stimulation) if this last medication was not successful. I was initially told that DBS surgery could minimize the tremors only in my hands and arms. I felt immediate relief, and a sense of hope for the first time in years. Leaving Stanford that day I finally had the answers I had searched for. Without success, our final medication trial had no effect on my tremor. Over the next six months my tremor worsened, and my voice became even more unrecognizable and hard to control. At my follow-up appointment at Stanford, I told Dr. Kilbane I was ready to move forward with the Surgical Consult.

I was confident in my experience thus far at Stanford, that DBS (Deep Brain Stimulation) could be my answer! Again, multiple tests and consultations were conducted to ensure that I was a candidate for DBS and could safely have surgery. The day that I had my surgical consult with Dr. Casey Halpern, I was impressed, to say the least. His knowledge and ability to relate to his patients was unlike my previous physicians. Dr. Casey Halpern’s bedside manner helped alleviate the concerns of my family and mine. Dr. Halpern immediately recognized my vocal tremor, and asked if that also bothered me. He asked if they could attempt to treat my vocal tremor during surgery. All of the risks and benefits of surgery were fully explained to me. I was ready. I was hopeful at the idea of a successful surgery for my hand tremors, although my voice was an added surprise that day. I was continually impressed with the staff and hopeful of a positive outcome.

Two months passed, and my surgery date was here. I was in surgery for seven hours, and awake for a great portion of it! They started with the left side of my brain, controlling the right side of my body. I could feel my tremors lesson, and I could hear the quiver in my voice decrease. Just hours out of surgery my family noted a dramatic change in my tremor, and stated that my voice sounded normal for the first time in over a year. I was told these were good results, but also known as a “honeymoon” phase. I was expected to see some return of the tremor in which my neurologists would make adjustments as needed to gain optimal results for me. Surprisingly though, months later my voice remained without tremor, although the tremors to my hand and arm returned and were able to be adjusted through stimulation. I am so grateful to Dr. Halpern, Dr. Kilbane, and all of the staff that helped me regain my life back.

Now six months later, I can truly say that DBS surgery significantly improved my life. It helped to reverse the symptoms that had taken over every aspect of my day. I can now talk to someone without having them ask me if I’m ok. I no longer have to be embarrassed when I speak or interact with people in my everyday life. The explanation every time I have a conversation is gone. I understand that this surgery comes with future adjustments and is a lifelong commitment, but it was worth it to me. I understand that my tremors are not gone, simply controlled. I am immensely thankful to Stanford Hospital and their outstanding staff for everything they have done and continue to do for me.

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Technical report
peer-reviewed

Deep Brain Stimulation for Essential Vocal Tremor: A Technical Report

  • Author Information
    Allen L. Ho Corresponding Author

    Department of Neurosurgery, Stanford University School of Medicine

    Omar Choudhri

    Department of Neurosurgery, Stanford University School of Medicine

    C. Kwang Sung

    Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center

    Elizabeth E. DiRenzo

    Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center

    Casey H. Halpern

    Department of Neurosurgery, Stanford University School of Medicine


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: This study did not involve human participants or tissue. Animal subjects: This study did not involve animal subjects or tissue. Conflicts of interest: The authors have declared that no conflicts of interest exist.

    Acknowledgements


    Article Information

    Published: March 10, 2015

    DOI

    10.7759/cureus.256

    Cite this article as:

    Ho A L, Choudhri O, Sung C, et al. (March 10, 2015) Deep Brain Stimulation for Essential Vocal Tremor: A Technical Report. Cureus 7(3): e256. doi:10.7759/cureus.256

    Publication history

    Received by Cureus: January 12, 2015
    Peer review began: January 13, 2015
    Peer review concluded: March 07, 2015
    Published: March 10, 2015

    Copyright

    © Copyright 2015
    Ho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Essential vocal tremor (EVT) is the presence of a tremulous voice that is commonly associated with essential tremor. Patients with EVT often report a necessary increase in vocal effort that significantly worsens with stress and anxiety and can significantly impact quality of life despite optimal medical and behavioral treatment options. Deep brain stimulation (DBS) has been proposed as an effective therapy for vocal tremor, but very few studies exist in the literature that comprehensively evaluate the efficacy of DBS for specifically addressing EVT. We present a technical report on our multidisciplinary, comprehensive operative methodology for treatment of EVT with frameless, awake deep brain stimulation (DBS).



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Create a free account to continue reading this article.

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Allen L. Ho, M.D., Resident Physician

Department of Neurosurgery, Stanford University School of Medicine

For correspondence:
allenlho@gmail.com

Omar Choudhri

Department of Neurosurgery, Stanford University School of Medicine

C. Kwang Sung

Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center

Elizabeth E. DiRenzo

Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center

Casey H. Halpern, M.D.

Department of Neurosurgery, Stanford University School of Medicine

Allen L. Ho, M.D., Resident Physician

Department of Neurosurgery, Stanford University School of Medicine

For correspondence:
allenlho@gmail.com

Omar Choudhri

Department of Neurosurgery, Stanford University School of Medicine

C. Kwang Sung

Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center

Elizabeth E. DiRenzo

Department of Otolaryngology - Head & Neck Surgery, Stanford University Medical Center

Casey H. Halpern, M.D.

Department of Neurosurgery, Stanford University School of Medicine